As it does each year at this time, the Aspen Ideas Festival is gathering great thinkers and great thoughts in the high, crisp, and rarefied air of the Colorado Rockies. I have been privileged to participate before, but this year, my invitation must have gotten lost in the mail. So I am not out in Colorado thinking, but back home in Connecticut, thinking about all that thinking.
One resulting reflection is that we may at times think too much. There is no shortage of very intelligent, highly educated people in my academic world. But perhaps there is something seductive about the pursuit of data that causes some in this domain to think that the pursuit of data is itself the objective. It shouldn't be. What most people want is for the data we derive to be applied to some demonstrable good, and for that -- we may not always need yet more data.
There is, for instance, the vivid image of a foot on fire. We have no randomized trials to inform the proper course of action. But I think the general body of knowledge about feet and fire suffices. So it is I have long maintained that were my foot to catch on fire, I would not need a randomized clinical trial, nor a fresh batch of data, to fetch a pail of water.
This matter has reverberations far beyond my own feet. In general in the area of lifestyle medicine, we have long had sufficient knowledge to eradicate as much as 80 percent of all chronic disease, but failed to apply it. The trouble here is not want of data about how best to protect our bodies, but want of action by the body politic. We like to contend that knowledge is power, but the gap between what we know, and what we do with what we know, belies that wishful thinking.
But perhaps we do think far too little at times, and about the most obvious of provocations. To address these, we have to move up a meter or two from the combustibility of feet, to where some of what is most importantly neglected is right under our noses. I have Humpty Dumpty in mind today.
I trust we all know the nursery rhyme: the wall, the fall, the 911 call, all the King's first responders. But have we ever really thought about what it means?
To a preventive medicine specialist, Humpty Dumpty is not mere verse for sleepy children, but a prosaic assessment of modern medicine, a plea for public policy, and a precautionary tale. And as it happens, there is discussion of Humpty Dumpty at this year's Aspen Ideas Festival, although it may be that no one there uses his name, or even recognizes him.
One of the central themes at this year's colloquy in the Rockies is "living better, not just longer." One of the questions posed to stimulate discussion in this space is: "Some scientists believe we may be able to extend life to 125 or beyond, but most of us want to live not just longer, but better. More medical care is one tool to do that, but how do we resist 'just-to-be-safe' overtreatment?"
From other copy on the conference website, and the caliber of participants, I have every reason to expect that the ensuing discussion will encompass both bodies and the body politic, culture and Blue Zones. But Humpty Dumpty is apt to go unmentioned, and that may be too bad.
A recent study in the journal Injury Prevention, for instance, was ostensibly much about the expansive, expensive, unintended mayhem induced by all the King's Horses and all the King's Men. The article explored the issue of "adverse medical events" in a representative sample of Medicare beneficiaries, in turn representing the general population age 65 and above. The investigators found that roughly one of every five Medicare participants treated as either in-patient or out-patient experienced an 'AME,' the majority occurring outside of hospitals. AMEs decreased functional ability, drove costs of care up sharply, and increased mortality significantly, and not just in the short term but over a span of many months.
If Humpty Dumpty is left out of the ensuing ruminations, then it may well be that, as posited on the Ideas Festival website, more medical care is one tool to help us all live longer. This study offers a sobering reality check about the potential adversities attached to that care, but we might constructively focus on tracking down the origins of such harms, and improving the system to expunge them. Drugs might be chosen more carefully, with more attention to potential interactions and unintended effects, and more scrupulous customization based on pharmacogenomics. Systems improvements may modify technologies to attenuate potential harms, and build in more layers of defense against potential human error. In the wishful world unacquainted with Humpty Dumpty, some amount of refinement, erudition, and continuous quality improvement allows the King's Horses and the King's Men to get the job done.
But for those of us familiar with Humpty Dumpty, there is this regrettable reality: even in 2014, science can't unscramble an egg.
I certainly, fully support efforts to attenuate medical error and AMEs to the irreducible minimum. But at the interface of frail people needing treatment, and the potency of the requisite modern remedies, that number will never be zero. There is a better way to avoid the harms of medical treatment -- and that is to need and get less of it, not more.
As a practicing physician, I am dubious about the potential for "more" medical care, however good, to provide us not just longer lives, but better. Certainly, I see no temptation toward 'just to be safe' care, since medical treatment is far from safe, as the new study -- one among many -- highlights.
Most importantly, the system euphemistically called "health care" is mostly about disease care. Mostly, it's about dealing with Humpty Dumpty after the fall. This is an important, worthy, even noble calling -- one I am proud to call my own. Treating illness and injury can restore quality to life, and extend its length.
But still, we can't unscramble eggs. The modern medical analogue is the vast burden of chronic diseases we cannot cure. Chronic diseases are the predominant scourge of modern epidemiology, and they require chronic treatment. As the combination of pathology and senescence advances in tandem, so generally does the need for more treatments. As the treatments aggregate into the frequent procedures and polypharmacy that prevail in an aging population with a high disease burden, so, inevitably, do the AMEs. The very notion of "just to be safe" medical treatment devolves quickly into naiveté.
We could do stunningly better. An emphasis on the power of lifestyle in medicine would be a good place to start. If medical care is to play a role here, it should be that of guiding hand more often, dispensing hand less. An emphasis on a very short list of lifestyle factors -- physical activity, dietary pattern, tobacco avoidance, adequate sleep, stress mitigation, social bonds (i.e., feet, forks, fingers, sleep, stress, and love) -- could be a routine clinical imperative, with health care professionals cultivating the "skillpower" of patients to make habitual, lifelong use of this best and safest of all medicines.
But lifestyle in medicine could only take us so far. Far more powerful would be lifestyle as medicine, where culture rather than just clinics is the dispensing spoon. As the minds' eyes in Aspen turn toward the world's Blue Zones, that is what they will see.
A clinical response can scoop up Humpty Dumpty from the base of that wall, and patch him back together. But chances are he will walk with a limp; he may become dependent on narcotics, which will induce chronic constipation; and he is subject to post-operative infections. In other words, Humpty Dumpty is a set-up for an AME, and all the while -- he and we know -- we can't unscramble eggs. We will never put his vitality back together again.
But culture could build lower walls; provide seat belts or air bags or safety nets; to say nothing of less sitting in the first place. Personal and public devotion to the cultivation of health at its origins could prevent the mess at the base of the wall. That's what the Blue Zones do. And as testimony to the uncomplicated feasibility of it, most of them do it inadvertently -- just by nurturing a traditional lifestyle.
Meanwhile we strive for elusive means to live longer and better, even as we sanction the predations that impose ever more chronic disease on ever younger people. How can a culture peddle multi-colored marshmallows to 7-year-olds prone to what was until recently "adult onset" diabetes and tell them it's all "part of a complete breakfast," then gather its intellectuals to wrestle with the challenge of healthy aging?
How odd, how ironic, and ultimately how indefensible -- to fret so much about the loss of vitality in our senescence, and invest so little in its cultivation across the life span. How odd, ironic, and indefensible to be willing to spend so much to stave off affects of aging, and think so little about the costs of our exploitative culture, borne predominantly by the young. How odd and ironic to be willing to do so much to achieve some semblance of youthful vigor in our old age, and so little to defend it against abuse in its native habitat, among our children and grandchildren.
As Humpty Dumpty gets old and teeters, we are invited to reflect on our strangely scrambled priorities. Perhaps it is maturity, rather than youth, that is wasted on all the wrong people.
-fin
David L. Katz, MD, MPH, FACPM, FACP is the founding director of Yale University's Prevention Research Center, President of the American College of Lifestyle Medicine, and author of 'Disease Proof.'